Form Dr 0200 - Colorado Special District Sales Tax Return Supplement Page 2

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Departmental Use Only

DR 0200 (07/11/16)

COLORADO DEPARTMENT OF REVENUE

Denver CO 80261-0013

(303) 238-SERV (7378)

Colorado Special District Sales

Tax Return Supplement

*160200==19999*

Mark here if this is an Amended Return

Acct. Number

Location/Juris Code

Due Date

Period

(MM/DD/YY)

(MM/YY-MM/YY)

0560-103

SSN

FEIN

Phone

(

)

Address

City

State

Zip

Name

Date

(MM/DD/YY)

Signature

Signed under penalty of perjury

in the second degree

(1-1)

(1-2)

— — —

•

1. Net taxable sales

Tax Rate

.0100 BRRTA

— — —

.0010 Football

— — —

2. Amount of sales tax

(3-1)

(3-2)

— — —

3. Excess tax collected

— — —

4. Total (add lines 2 & 3)

— — —

5. a. Service fee rate

(5-1)

(5-2)

— — —

b. Service fee allowed vendor

— — —

6. Sales Tax Due (line 4 minus line 5b)

(7-1)

(7-2)

— — —

7. Penalty

(8-1)

(8-2)

— — —

8. Interest

— — —

9. Total each tax (add lines 6, 7 & 8)

10. Total Amount Owed (Add all columns on line 9. Pay this amount with your return)

(355)

Paid by EFT

.0 0

The State may convert your check to a one time electronic banking transaction. Your bank account may be debited as early as the same day received by the State.

If converted, your check will not be returned. If your check is rejected due to insufficient or uncollected funds, the Department of Revenue may collect the payment

amount directly from your bank account electronically.